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Based upon observation and interview, the facility failed to ensure aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7 and continuously maintained free of all obstructions to full use in care of an emergency as required by 19.2.1 and 7.1.10.1. This deficient practice could affect all occupants in the event of a fire.

Findings Include:

* On 01/08/19, at approximately 10:12 AM, the following observation was made and confirmed by interview with Facility Manager H, that wheelchairs are being stored in the 5-South landing, behind psych and obstructing access to Stairwell SGH-21.

* On 01/09/19, at approximately 10:16 AM, the following observation was made and confirmed by interview with Facility Manager H, that linen carts are being stored in the 5-East corridor.

* On 01/09/19, at approximately 2:12 PM, the following observation was made and confirmed by interview with Facility Manager H, that a 65-gallon paper recycling container stored in the corridor at room E148.

Based upon observation and interview, the facility failed to ensure that doors in a required means of egress are not equipped with a latch or lock that requires the use of a tool or key from the egress side unless meeting the special locking arrangements for clinical needs in accordance with 19.2.2.2.5.1 and 19.2.2.2.6, special needs locking arrangements in accordance with 19.2.2.2.5.2, delayed egress locking in accordance with 19.2.2.2.4, access-controlled egress doors in accordance with 19.2.2.2.4, or elevator lobby exit access in accordance with 19.2.2.2.4.

This deficient practice could affect all occupants in the event of a fire.

Findings Include:

* On 01/09/19, at approximately 11:15 AM, the following observation was made and confirmed by interview with Safety Director "V", 5-West Stairwell Doors, 6, 7, & 8 are equipped and marked as delayed egress locks. However, the delayed egress function did not operate when tested.

* On 01/09/19, at approximately 12:45 PM, the following observation was made and confirmed by interview with Safety Director "V", 2-West Stairwell Doors, 6, 7, & 8 are equipped and marked as delayed egress locks. However, the delayed egress function did not operate when tested.

* On 01/08/19, at approximately 9:30 AM, the following observation was made and confirmed by interview with Facility Manager "H" 3-East Stairwell Doors from "Mother/ Baby Unit" are equipped and marked as delayed egress locks. However, this floor is not fully sprinkler protected.

* On 01/08/19, at approximately 10:50 AM, the following observation was made and confirmed by interview with Facility Manager "H" 2-East Stairwell Doors are equipped and marked as delayed egress locks. However, this floor is not fully sprinkler protected.

Based upon observation and interview, the facility failed to ensure that exit and directional signs are displayed in accordance with 7.10, continuously illuminated, and served by the emergency lighting system as required by 19.2.10.1.

This deficient practice could affect 150 occupants in the event of a fire.

Findings Include:

On 01/09/19, at approximately 10:10 AM, the following observation was made and confirmed by interview with Safety Director "V", that a fire exit sign in the 7th floor, stairwell 9 directs persons to the roof and not an exit.

Based upon observation and interview, the facility failed to ensure that hazardous areas are protected by a fire barrier having a 1-hour fire-resistance rating or protected by an automatic extinguishing system in accordance with 8.7.1 as required by 19.3.2.1.

This deficient practice could affect All occupants in the event of fire.

Findings Include:

* On 01/09/19, at approximately 10:25 AM, the following observation was made and confirmed by interview with Safety Manager "V", that the door to the 6th floor Pre/ Post OP M622 soiled utility room, did not fully close and self-latch when tested and has the potential to allow products of combustion to enter the corridor in the event of a fire.

* On 01/08/19, at approximately 10:25 AM, the following observation was made and confirmed by interview with Facility Manager "H", that the door to E50R did not close to a smoke tight seal. The 1/4" gap has the potential to allow products of combustion to enter the corridor in the event of a fire.

* On 01/08/19, at approximately 10:57 AM, the following observation was made and confirmed by interview with Facility Manager "H", that a large section of drywall is missing from the ceiling in Environmental Services Closet E40Q and no longer meets the 1-hour fire separation requirement.

* On 01/08/19, at approximately 11:12 AM, the following observation was made and confirmed by interview with Facility Manager "H", that two 1/2" penetrations were found above the door to Housekeeping E30M and have the potential to allow products of combustion to enter the corridor in the event of a fire.

* On 01/08/19, at approximately 11:25 AM, the following observation was made and confirmed by interview with Facility Manager "H", unsealed wall penetrations above the door to storage room E50B and has the potential to allow products of combustion to enter the corridor in the event of a fire.

* On 01/09/19, at approximately 9:50 AM, the following observation was made and confirmed by interview with Facility Manager "H", wall penetrations/ missing drywall in room E571-1 and has the potential to allow products of combustion to enter the corridor in the event of a fire.

* On 01/08/19, at approximately 9:15 AM, the following observation was made and confirmed by interview with Facility Manager "H", the door to electrical room M603 is not fire rated.

* On 01/08/19, at approximately 1:27 PM, the following observation was made and confirmed by interview with Facility Manager "H", that Mechanical Room M502 is not sprinkler protected and the door is not rated.

Based upon observation and interview, the facility failed to ensure that cooking facilities are protected in accordance with NFPA 96 unless meeting the requirements of 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.4.4 as required by 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, and TIA 12-2.

This deficient practice could affect 200 occupants in the event of a fire.

Findings Include:
* On 01/09/19, at approximately 3:00 PM, the following observation was made and confirmed by interview with Safety Director "V", that filters in the exhaust hood are missing.

* On 01/09/19, at approximately 3:05 PM, the following observation was made and confirmed by interview with Safety Director "V", that none of the wheeled cooking equipment underneath the exhaust hood had wheel tracks, to assure correct placement.

* On 01/09/19, at approximately 3:15 PM, the following observation was made and confirmed by interview with Safety Director "V", None of the kitchen staff were familiar with emergency operation of the hood suppression system, including:

- Location of suppression system pull station
- When and how to activate
- Types of extinguisher's (Uses for each)
- Location of fire alarm pull station
- Procedures for fires not under hood

Based upon observation and interview, the facility failed to ensure that Alcohol Based Hand Sanitizers are protected in accordance with 8.7.3.1 unless meeting all conditions as required by 19.3.2.6 and 42 CFR Parts 403, 418, 460, 482, 483, and 485.

This deficient practice could affect All occupants in the event of a fire.

Findings Include:

* On 01/09/19, at approximately 11:35 AM, the following observation was made and confirmed by interview with Safety Director "V", Alcohol Based Hand Sanitizers at rooms W324/W325, W319/W320, W307/W308, W303/W304 do not meet the minimum horizontal spacing requirements.

* On 01/09/19, at approximately 1:00 PM, the following observation was made and confirmed by interview with Safety Director "V", Alcohol Based Hand Sanitizers at rooms W207/W208, W209/W210, W222/223 do not meet the minimum horizontal spacing requirements.

* On 01/09/19, at approximately 1:35 PM, the following observation was made and confirmed by interview with Safety Director "V", Alcohol Based Hand Sanitizers at rooms W503/W504, W521/W522, W524/W525 do not meet the minimum horizontal spacing requirements.

* On 01/09/19, at approximately 1:45 PM, the following observation was made and confirmed by interview with Safety Director "V", Alcohol Based Hand Sanitizers at rooms W419/W420 & W403/W404 do not meet the minimum horizontal spacing requirements.

Based upon observation and interview, the facility failed to ensure that interior wall and ceiling finishes have a flame spread rating of Class A or B unless permitted to be reduced by 10.2.8.1 as required by 19.3.3.1 and 19.3.3.2.

This deficient practice could affect 75 occupants in the event of fire.

Findings Include:

* On 01/09/19, at approximately 1:15 PM, the following observation was made and confirmed by interview with Safety Director "V", that cardboard was being used in place of approved ceiling tile, in room M244.

Based upon observation and interview, the facility failed to ensure a fire alarm system is installed in accordance with NFPA 70 and NFPA 72 as required by 19.3.4.1, 9.6, and 9.6.1.8.

This deficient practice could affect All occupants in the event of a fire.

Findings Include:

* On 01/08/19, at approximately 10:41 AM, the following observation was made and confirmed by interview with Facility Manager "H", that the door to the "Securitron" door locking panel, in the Psych janitor's closet, was open.

* On 01/08/19, at approximately 11:55 AM, the following observation was made and confirmed by interview with Facility Manager "H", that office E50R requires a fire alarm visual appliance.

* On 01/08/19, at approximately 10:45 AM, the following observation was made and confirmed by interview with Facility Manager "H", that new smoke detectors have been installed in elevator lobbies, but the old units were never removed.

Based upon observation and interview, the facility failed to ensure that hospitals required by construction type are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13 as required by 19.3.5.1 through 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, and 9.7.1.1(1).

This deficient practice could affect 100 occupants in the event of a fire.

Findings Include:

* On 01/09/19, at approximately 11:30 AM, the following observation was made and confirmed by interview with Safety Director "V", that the Pulmonary Function Lab is not sprinkler protected.

* On 01/09/19, at approximately 10:15 AM, the following observation was made and confirmed by interview with Facilities Manager "H", that missing ceiling tiles around the automatic sprinkler heads in room E50B. This deficiency could delay proper operation of the sprinkler heads.

* On 01/09/19, at approximately 1:15 PM, the following observation was made and confirmed by interview with Facilities Manager "H", that missing ceiling tiles in electrical room E40C. This deficiency could delay proper operation of the sprinkler heads.

Based upon observation and interview, the facility failed to ensure that automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25 and records are readily available as required by 9.7.5, 9.7.7, 9.7.8, and NFPA 25.

This deficient practice could affect 40 occupants in the event of a sprinkler head failure.

Findings Include:

* On 01/09/19, at approximately 10:27 AM, the following observation was made and confirmed by interview with Safety Director "V", the sprinkler valve in the Pre/Post OP Room M436 is not labeled.

Based upon observation and interview, the facility failed to ensure doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, resist the passage of smoke, equipped with a means suitable for keeping the door closed, and there is no impediment to the closing of doors as required by 19.3.6.3 and 42 CFR 403, 418, 460, 482, 483, and 485.

This deficient practice could affect 100 occupants in the event of a fire.

Findings Include:

* On 01/09/19, at approximately 11:25 AM, the following observation was made and confirmed by interview with Safety Director "V", that a communication board access door, in corridor at room M525, does not close to a positive latch.

Based upon observation, record review and interview, the facility failed to ensure that doors in smoke barriers are 1 3/4 inch solid bonded wood-core doors or construction that resists fire for 20 minutes, are self-closing or automatic-closing and provide a minimum width of 32 inches as required by 19.3.7.6, 18.3.7.8, and 19.3.7.9.

This deficient practice could affect All occupants in the event of a fire

Findings Include:

* On 01/09/19, at approximately 11:00 AM, the following observation was made and confirmed by interview with Safety Director "V", that the 6th floor cross-corridor smoke barrier doors at room M618 are labeled as a smoke compartment, but review of life safety drawings indicate differently.

* On 01/08/19, at approximately 9:40 AM, the following observation was made and confirmed by interview with Facilities Manager "H", the auto-closing smoke barrier doors, at 4th floor South elevator lobby, are not fully closing.

* On 01/08/19, at approximately 2:33 PM, the following observation was made and confirmed by interview with Facilities Manager "H", the rating labels have been removed from the smoke barrier doors at room E355.

* On 01/09/19, at approximately 1:15 PM, the following observation was made and confirmed by interview with Facilities Manager "H", the smoke barrier doors at room 5486 were blocked by beds.

* On 01/09/19, at approximately 9:40 AM, the following observation was made and confirmed by interview with Facilities Manager "H", drawing's and placards indicate smoke barrier doors at Department of Medicine are rated. However the labels have been removed.

* On 01/09/19, at approximately 1:17 PM, the following observation was made and confirmed by interview with Facilities Manager "H", the smoke barrier doors at room E254 are not rated.

* On 01/09/19, at approximately 1:20 AM, the following observation was made and confirmed by interview with Facilities Manager "H", the smoke barrier doors at room E259 are not fully closing.

* On 01/09/19, at approximately 2:40 PM, the following observation was made and confirmed by interview with Facilities Manager "H", the smoke barrier doors at 1-East are not labeled.

* On 01/09/19, at approximately 2:50 AM, the following observation was made and confirmed by interview with Facilities Manager "H", all smoke barriers in the Emergency Department need to be labeled and indicated on drawings.

On 01/08/19, at approximately 1:00 PM, the following observation was made and confirmed by interview with Facilities Manager "H", the smoke barrier doors at room M403A are no longer being maintained. Staff in wing were not told about this and are still using area for shelter in the event of a fire.

Based upon observation and interview, the facility failed to ensure that power strips are listed for the area in which they are used as required by 10.2.3.6 of NFPA 99 and 400-8 of NFPA 70, and TIA 12-5 and that extension cords are placed in use only temporarily as required by 10.2.4 of NFPA 99 and 590.3(D) of NFPA 70.

This deficient practice could affect All occupants in the event of

Findings Include:

* On 01/09/19, at approximately 10:36 A.M., the following observation was made and confirmed by interview with Facilities Manager "H", that a refrigerator was found plugged into a power strip.

Based upon observation and interview, the facility failed to ensure that storage of nonflammable gases meet all requirements of 11.3.1 through 11.3.4 and 11.6.5 of NFPA 99.

This deficient practice could affect 100 occupants in the event of fire.

Findings Include:

* On 01/09/19, at approximately 12:50 PM, the following observation was made and confirmed by interview with Safety Manager "V", that soiled utility room W20E contained unsecured oxygen cylinders.